GW1--03364_Well Construction - GW1_20240610

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
J U\N `! (b I'D \ \ 14.WATER ZONES
Well Contractor ame � FROM TO DESCRIPTION
ft. ft
( G/' PI 1 ft ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap lcable)
Morgan Well&Pump, INC FROM TO DIAMETERDIAMETER THICKNESS MATERIAL
�, a ft. f ft. 1 61/8 in. sdr-21 PVC
---— -�� - . -... bl. (�/Z 1u L'.1 ER Th TBI Cek,S OR Gi a,tl Wr i io3 iuui),2.Well Construction Permit#: "4 V t t'6 - FROM '--TO '—DIAMETER— THICKNESS M sTERrAL'- ---- -
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft. .in.
ft.3.Well Use(check well use): ft.
rn.
Water Su 1 Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE _ THICKNESS MATERIAL
EtAgricultural jMunicipal/Public ft. ft. in.
0Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
DIndustrial/Commercial U Residential Water Supply(shared) 18.GROUT
I l lrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft bentontte poured
0Monitoring EIRecovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge EIGroundwater Remediation
19.SAND/GRAVEL,PACK(if applicable)
Aquifer Storage and Recovery QSalinity Banier FROM - TO , MATERIAL - EMPLACEMENT METHOD
Aquifer Test Ell Stormwater Drainage ft. ft
Experimental Technology 0 Subsidence Control ft ft.
10 Geothermal(Closed Loop) 0 Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) [t. g 13(O 1 ri-9
tr
4.Date Well(s)Completed: Z_ZL_ Well ID# '"Z�ff• q p ft 54 l dry
5a.Well Location: C6 z ft 5 ' ft. bi��� ,K
C r A r k 891 /1; s let ft 7_wuC✓ ft. GErevi l st
Facility/Owner Name Facility ID#(if applicable) ft ft. 1— t J` 1
90 y6 Menv•l (fie l l e/ QC1 ft. ft. ;...
Physical Address,City,and Zip ft. ft. t U t,l tV 1 l 0 624
`/tD i 4 21.REMARKS J u.4
County Parcel Identification No.(PIN) ►fi4OrW `e 1• �r�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,onnefflat/l'on]g is sufficient) 22.Certification:
, 5`T 1 / 6 N ��' 7 W �r� �1 / �f-1 )
`G
eiINP.tor
6.Is(are)the well(s)MPermanent or Temporary Signa �ified Wenactor Date
By signing this form,I hereby certity that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or jNo with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. '
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: fS (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 1/8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
•
rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: air 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type: granulated chlorine Amount:
the address(es) above, also submit one copy of this form within 30 days of
�' �� completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 '